A new approach to M&A helps

healthcare companies grow in Asia

Healthcare companies looking for growth in Asias
developing markets are turning to M&A, but they need
a different playbook than the one that brought them
success in the West.
By Matthew Collier and Grace Shieh
Matthew Collier is a Bain & Company partner based in Shanghai and a member
of the rms Global Healthcare practice. Grace Shieh is a Bain principal based
in Shanghai.
Copyright 2013 Bain & Company, Inc. All rights reserved.
A new approach to M&A helps healthcare companies grow in Asia
1
As their core markets in the West stagnate or decline,
multinational healthcare companies are looking for
growth in Asias developing markets. But despite the
growing economies in China, India and elsewhere in
Asia, success too often eludes the multinationals that
set off in pursuit of it. Organic growth can be difcult
to achieve and maintain in countries where aggressive
and nimble local competitors claim a clear advantage
in both cost and commercial capabilities. And the
alternative, mergers and acquisitions (M&A), all too
often delivers disturbingly mixed results.
Consider Sanos $602 million acquisition of Indian
vaccine maker Shantha Biotechnics. The deal failed to
live up to analysts forecasts after manufacturing troubles
wiped out $340 million in sales. The World Health
Organization canceled its contract for ve childhood
vaccines after white sediment was found in some vials.
Learning from such experiences, winning healthcare
companies are discovering a unique approach to inorganic
growth that sets them up for success in Asia over the
long haul. They use a portfolio management strategy
that builds a combination of sustainable assets across
countries, sectors and risk proles, relying on an M&A
toolkit tailored to the unique attributes of these emerging
markets. Companies sometimes nd this approach at
odds with the strategies that helped them grow and
prot in their established markets, as it requires an
entirely different view of M&A and post-merger inte-
gration. But those that embrace this approach find
themselves outpacing the competition as they gain
solid footing in new, high-growth markets. When Philips
purchased Shenzhen Goldway Industrial in 2008, the
acquisition allowed Philips to surpass the competition
and become the patient monitoring market leader in
only three years.
Going where the growth is
Per capita healthcare expenditures in developing markets
are still dwarfed by those of the developed world. Chinas
healthcare spending per capita represents 5.7% of its
GDP; Indias healthcare expenditures are 3.8%; and
Indonesias are 2.6%. These countries have a long way
to go to reach the USs level, where 18% of GDP is
devoted to healthcare. But the combination of scale
and economic growth makes Asias developing economies
some of the hottest markets for pharmaceuticals and
medical devices (se Figure 1). Already, Chinas economy
ranks No. 2 on the world stage, and many are forecasting
that Asias healthcare expenditures will grow two to
three times faster than the global average, especially
in countries like China and Thailand, spurred in part
by government policy and investment. Even while we
expect that Chinas average growth rate will decelerate
over the course of this decade to approximately half its
growth rate in the previous two decades, its healthcare
expenditures are projected to continue growing at 12%
annually for the rest of the decade, fueled by demographics
and advancing government policies affecting health
benets, coverage access and availability.
The combination of scale and economic
growth makes Asias developing econ-
omies some of the hottest markets for
pharmaceuticals and medical devices.
Analysts expect global healthcare companies to see a
disproportionate amount of their growth coming from
developing markets. Forecasts for GlaxoSmithKline, for
example, project the companys pharmaceutical sales
in Asia to increase six times its global rate. Asia sales of
Medtronics medical devices will grow an annual 11%
between 2011 and 2015, according to some estimates
far surpassing its 3% global sales average.
Capturing this growth requires new business models
that can be difcult and expensive for multinationals
to build. For example, the biggest opportunities in
medical devices lie in the market for good enough
productsthe mid-market segment of reliable, low-cost
products that are priced signicantly below multinationals
premium offerings (se Figure 2). The trouble is,
producing good-enough products and deploying the
2
A new approach to M&A helps healthcare companies grow in Asia
Figure 1: Asias emerging markets healthcare expenditures are forecast to grow two to three times faster
than the global average
Sources: Espicom; BMI; Bain analysis
Healthcare expenditure (USD)
0
3
5
8
10
$11T
2007
5.3
2008
5.8
2009
6.0
2010
6.4
2011
6.9
Established 2020
EMEA
Americas
10.4
Other APAC
Japan
Indonesia
India
China
6%
4%
25%
13%
17%
12%
11%
7%
5%
3%
12%
15%
12%
-1%
2%
5%
CAGR
(0711)
CAGR
(1120)
Figure 2: In China, more growth will take place in the good-enough segment
Source: Bain Experience Center
Medtech sector overview A closer look at stents
China medtech market by segment
0
5
10
15
20
$25B
2003
6.7
2007
11.2
2012
High-end
Mid-end
Low-end
20.6
8%
20%
11%
CAGR
(0312)
2004
Local players
Global players
1x
2008
JW Medical
Lepu
Microport
Other
BSC
J&J
Medtronic
3x
10%15%
40%70%
CAGR
(0408)
A new approach to M&A helps healthcare companies grow in Asia
3
leaner go-to-market models that are required to support
them run counter to the corporate DNA of most
multinationals. In developed and developing markets
alike, most multinationals have built their businesses
and reputations exclusively on the premium market
segment. Many that have tried to shift gears have
found themselves faced with multiyear investments
that failed to produce the desired results. These failed
efforts have further reinforced multinationals instincts
to exclusively maintain premium offerings, even while
they watch value competitors gain share. In cardiac
stents, for example, Johnson & Johnson created the
market in China and witnessed new local value entrants
grab more than 60% of the market in just three years
after the products initial launch. Ultimately, Johnson &
Johnson exited the business.
Producing good-enough products and
deploying the leaner go-to-market mod-
els that are required to support them
run counter to the corporate DNA of
most multinationals.
Whether its medical devices, pharmaceuticals or
healthcare services, growing in Asias emerging markets
requires a broad distribution network and an ecosystem
that includes regulators and other public relationships.
For companies pursuing organic growth, these channels
are challenging to develop quickly and efciently enough
to compete. Multinationals also need a host of special
capabilities, everything from local teams with deep
market knowledge to lean and nimble operating struc-
tures. These, too, are tough to build organically. The
challenges intensify with rising demands by corporate
headquarters for deeper budget cuts alongside escalating
demands for growth.
Tricky business in Asia
Enter M&A. To quickly ll the gaps, multinationals
increasingly turn to acquisitions. Healthcare M&A
activity in the region is healthy, with pharmaceutical
companies leading the pack in the number of transactions.
But M&A is tricky business in Asia, where so many
companies get tripped up, particularly when it comes
to performing diligence on targets and effectively
integrating and executing after the deal closes. The
challenge is amplied by another factor: The shortage
of available assets has delivered inated valuations.
Given high valuations, acquirers need a strategic logic
that looks further into the future than the traditional
near-term return on investment (ROI) of developed-
world transactions. Beyond the high cost and shortage
of assets, there are other signicant challenges in Asia:
High volatility from sociopolitical uncertainty and
rapid policy changes, fragmented regional markets,
diverse local competition, and justied concerns over
quality and compliance all bring uncertainty into each
and every transaction.
Its no surprise, then, that many healthcare companies
nd it difcult to get M&A right, as crucial as it is for
growth. The healthcare industry is littered with more
than its share of ill-fated deals. But despite troubled
deals, recent Bain & Company analysis of corporate
deal activityboth within and outside of healthcare,
over the last 11 yearshas found that M&A as a growth
strategy has been quite successful, and businesses
that do this well grow more shareholder value than
those that dont (se Figure 3). Furthermore, deal
makers that were frequent acquirersinvesting in
multiple deals over timeand followed a disciplined,
repeatable model came out the biggest winners. A
company that does more acquisitions is likely to identify
the right targets more often, develop the capabilities
required to vet deals and build the organizational
muscles to be more effective at integrating acquisi-
tions. That experience is reected in the data. As a
group, companies across the globe that engaged in
occasional M&A activity averaged 4.8% total shareholder
returns (TSR), compared with 3.3% for those that were
inactive. Yet, the most active companies in our study
reported a TSR of 6.4%almost double that of their
inactive counterparts.
4
A new approach to M&A helps healthcare companies grow in Asia
Why invest?
Whether its an acquisition, joint venture or strategic
partnership, a company must know the compelling
reason behind the deal. Companies look to their unique
needs and investment horizons to help them dene
their portfolio strategies. Beyond the conventional
wisdom of near-term ROI, a portfolio strategy should
consider the potential for improving market position
and growing share alongside the risks and opportunities
for the companys core business over the long term.
It should also take into account the capabilities and
access offered, as well as the possibility of gaining an
early-mover advantage. Also important: the longer-term
opportunities to export out of the region, back into the
developed markets. By overemphasizing deal valuation
or price, companies risk participating in too few deals
and potentially nding themselves relegated to the role
of a niche player, even in their core markets. Portfolio
returns should trump the returns of individual assets.
The goal is to create a sustainable leadership position
Our analysis strongly suggests that executives will
need to focus even more on M&A to meet the growth
expectations of their investors. The big trick in Asia is
to adapt M&A strategy to the markets unique condi-
tionsand the nuances of every country and sector.
Our experience and analysis also show that a portfolio
management approach delivers the best results. This
is particularly true in regions where scale deals are
few in number (se Figure 4). In China, for example,
only 6 local medtech companies have revenues in
excess of $200 million. Portfolio management involves
creating something akin to a mutual fund of assets
placing well-considered multiple bets that create a
strategic platform for growth. Based on our experience
with healthcare clients in emerging Asia, weve identi-
ed the ve key questions companies must ask and
answer to successfully execute an M&A strategy
(see Figure 5).
Figure 3: Serial acquirers create the most value from M&A
Note: N=1,616 companies; number of deals includes all deals; relative deal size for deals with undisclosed value assumed at median sample deal size of 1.3% of market
capitalization; cumulative relative deal size 20002010 based on sum of relative deal sizes vs. respective prior year-end market capitalization
Sources: Bain M&A Study 2012; Dealogic; Thomson; Bain SVC Database 2011
Acquisition
frequency
Cumulative relative deal size
Above-average
deal activity
(>1 deals per year)
Below-average
deal activity
(<1 deal per year)
Average TSR for all
companies in sample:
4.5%
75% of buyers market cap >75% of buyers market cap
Inactives
3.3%
Mountain Climbers
6.4%
Serial Bolt-ons
4.5%
Large Bets
4.0%
Selected Fill-ins
4.6%
Annual total shareholder returns (CAGR 20002010)
A new approach to M&A helps healthcare companies grow in Asia
5
Figure 4: China and India offer few scale assets for partnership or M&A
Note: *Scale assets defined as exceeding revenue levels listed by sector
Sources: Capital IQ; analyst reports; literature search, company websites; company reports
China
India
Number of scale assets*
Number of scale assets*
0
2
4
6
8
10
Pharma
(>$200M)
10
OTC
(>$100M)
8
TCM
(>$300M)
9
Medtech
(>$200M)
6
Retail
(>$500M)
5
Provider
(>$30M)
5
Distribution
(>$1B)
3
CRO
(>$100M)
2
Insurance
(>$200M)
0
5
10
15
20
15
1
4
17
2
3
1
Pharma and CHC
(>$200M)
Medtech
(>$200M)
Retail
(>$100M)
Provider
(>$30M)
Distribution
(>$500M)
CRO
(>$50M)
Insurance
(>$200M)
Figure 5: Bains playbook for healthcare success in Asia-Pacic starts with ve key questions
Source: Bain & Company
Why
invest?
APAC
participation
model
With
which
capabilities?
Where
to invest
when?
What
to do?
How
to participate?
Prioritized countries and sectors
When to invest is based
on time to equilibrium
(when clear winners emerge)
Greenfield, partner, JV or M&A based on
sector-specific regulatory and compliance
environment and competitive dynamics
M&A process tailored to unique opportunities
and risks, with best practices in:
Diligence
Valuation
Integration
Talent and relationship
Culture
Build talent and capabilities
to replicate
Clear, compelling investment thesis
driven by portfolio strategy
6
A new approach to M&A helps healthcare companies grow in Asia
Figure 6: When potential is balanced with viability, the clear priorities in China are pharma and medtech
Providers
Pharmacy
Distributors
Pharma
Providers
Medtech
CHC
Pharma
Insurance
CHC
Medtech
IT
Insurance
IT
Source: Bain & Company
Country prioritization Sector prioritization
Government
openness
to MNCs
Compliance
Globalization
Infrastructure
Scale
Growth
C
o
u
n
t
r
y

v
i
a
b
i
l
i
t
y
High
High
Low
Thailand
Vietnam
Malaysia
Low
Indonesia
Philippines
$150B
Total
healthcare
spend
Country potential
Profitability
Influence on
external markets
India
China
2020
2011
Government
openness
to MNCs
Compliance
Number of
potential
targets
Scale
Growth
Profitability
Influence on
external markets
China India
Rapid emergence of winners Slow emergence Limited evolution
Country/sector potential
C
o
u
n
t
r
y
/
s
e
c
t
o
r

v
i
a
b
i
l
i
t
y
High
High
Low
Low
$50B
2011
revenue
and protable growth in a local market, with options
for reverse innovation and eventual growth at home
in the evolving developed markets.
Where to invest and when?
Companies need to diversify across asset classes,
creating a balanced portfolio by taking multiple bets
across countries, sectors and steps in the value chains.
Abbotts 2010 acquisition of Solvay Pharmaceuticals
allowed the company to expand its product range in
the good-enough segment. Sanos 2011 purchase of
Universal Medicare strengthened the companys position
in the mass segment.
Typically, two dimensions govern the where-and-when
decision (see Figure 6). First, acquirers should
consider a countrys potential for scale, growth, prot-
ability and inuence on external markets. Second, they
should evaluate a countrys viabilityeverything from
the governments openness to multinationals, to expo-
sure to compliance risks, to such infrastructure issues
as the number of hospital beds per capita. Balancing
potential and viability, China and India surface as the
clear leaders among Asia-Pacic markets.
But within any given country, theres wide variability
in potential across categories. Take Chinas pharma-
ceutical distribution sector. The market is highly
fragmented and impacted by government policies that
favor locals in the roll up of preferred assets. The
result: Few multinationals are participating. For
example, both McKesson and AmerisourceBergen
have shied away. By comparison, the orthopedics
implant sector is increasingly characterized by rapid
consolidation, reforms, reimbursement and market
dynamics that favor the combination of scale value
players alongside premium multinational technology
and brands. As a result, two top local players, Kanghui
and Trauson, were recently acquired by multinationals
Medtronic and Stryker, respectively.
A new approach to M&A helps healthcare companies grow in Asia
7
Finally, timing is critical. Key questions for any sector
are, when will the value segment develop? when will
clear winners emerge? and when must I act? To nd
answers, most successful companies systematically
evaluate a host of factors across their markets, from
therapeutic pathways, to entry barriers, to local and
regional market diversity, to competitive maturity and
capability t.
How to participate?
As they build their asset portfolios, winning healthcare
companies create a balanced mix of M&A, joint ventures,
partnerships and greeneld investments. Choosing
the right format means carefully weighing regulatory
and competitive dynamics. For example, in the phar-
maceutical and medtech sectors, Chinas regulatory
and compliance requirements, combined with industry
dynamics, make M&A the strongest option. For multi-
nationals interested in acquiring hospitals in India,
regulations, target availability and competitive dynamics
are suitable to M&A and joint ventures.
What to do?
The challenges of doing business in emerging markets
are well known. The lack of financial transparency
makes due diligence difficult. Valuations are often
inated. Integration is complicated. Talent is scarce,
and cultural gaps persist across countries. But winning
healthcare companies have developed ways to com-
pensate. They adjust for high valuations by focusing
on long-term strategic value beyond ROI and accept
longer paybacks. They take a go-slow, judicious approach
to integration, particularly in customer-facing functions.
They keep talent and key personnel with incentive
plans and elevated positions, and they nail down those
critical details before the deal closes. When Philips
bought Shenzhen Goldway, for example, it offered
retention packages to line managers along with long-
term service awards. Most important, it positioned the
Goldway leadership at the top of a new business unit,
thus retaining the relationships and steerage that were
at the root of the companys success.
Consider due diligence. Before PerkinElmer purchased
Sym-Bio, it embarked on a diligence process that was
tailored to the local market. It relied heavily on primary
research performed in parallel by professional rms
and internal line experts. In addition to the business
model and company nancials, it assessed the man-
agement, intellectual property, environmental and legal
risks of pursuing the deal. All of this was enabled
by reach around diligencethe company reached
out to market constituencies, including competitors,
customers and suppliers, to bolster information that
was available from the company.
As they build their asset portfolios, win-
ning healthcare companies create a
balanced mix of M&A, joint ventures,
partnerships and greeneld investments.
Successful acquirers take a similarly cautious approach
to integration, often using a wait-and-see model. Philips
only integrated with Shenzhen Goldway where it mat-
tered most during the rst three yearsin areas such
as distributor managementand then performed a
full integration afterward as traction, capabilities and
understanding permitted. The thoughtful, low-and-slow
approach to integration was critical to the deals success.
By providing financial support and cash incentives,
Philips was able to retain nearly all of Goldways
distributors. It even managed channel risk with a
comprehensive compliance program, which included
distributor background checks deployed in such a way
as to not lose traction in the market.
And then there are the inevitable cultural gaps. Bain
research found there was a huge difference between
deals that proactively identied cultural issues in due
diligence and addressed them in integration, and those
that did not, regardless of the complexity of cultural
issues. A proactive approach netted above 5% higher
stock price performance compared to sector indices,
8
A new approach to M&A helps healthcare companies grow in Asia
What are the skills and capabilities for a successful
repeatable M&A model? The best companies build a
dedicated core M&A team with rich transactional and
integration experience. They involve product-line staff
early on and make them accountable for long-term
results. They set clear M&A policy and target assessment
criteria, institutionalizing the deal-making process with
clear roles and responsibilities. They create a new
playbook for integration that includes compliance and
quality standards and is distinct from the one they use
in developed markets.
Building a healthcare business in emerging Asia means
looking to M&A, joint ventures and other deals that
will help a company gain traction. But the difference
between success and failure rests on tailoring the
approach to the unique characteristics of Asias diverse
marketsusing these ve basic questions to create a
high-return mutual fund of assets.
versus a more than negative 4% share-price underper-
formance in deals that failed to identify and negotiate
cultural hurdles. Its hard to overstate the importance
of having a capable team on the ground to bridge the
gap between the two merging entities.
With which capabilities?
Most successful companies develop Repeatable Models

unique, focused sets of skills and capabilities that they

can apply to new products and new markets over and
over. Our own analysis and experience conrm the power
of repeatability in the world of M&A. An acquirers ex-
pertise in nding, analyzing and executing the trans-
action, and then in integrating the two companies when
the deal is done, determines the success of the typical
deal. Frequent acquirers create a repeatable M&A model,
one that they return to again and again to launch and
negotiate a successful deal.
Repeatable Models

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